Cal-Cobra Election Form - Blue Shield Of California printable pdf download

Cal-COBRA Election Form

Please return completed form to: Blue Shield of California Cal-COBRA, PO Box 629009, El Dorado Hills, CA 95762-9009.

Blue Shield of California will accept those individuals already on Cal-COBRA coverage from a prior carrier. If an employer changes to a Blue Shield

health plan, you may continue Cal-COBRA coverage with Blue Shield for the duration of your Cal-COBRA coverage period based on your original

qualifying event.

I hereby elect Blue Shield of California subscriber coverage and/or family coverage for my eligible dependents listed below as may be contracted

for by the group contract holder. Blue Shield benefits, dues, and contract modifications will be in accordance with the group service contract and

as allowed under Cal-COBRA.

Employee information

Last name

First name

Blue Shield of California ID/SSN

Group/section number

Date of original qualifying event

Original qualifying event

Check one, enter required date

c Termination or reduction in covered employee’s hours (last day worked) ______/______/______

c Divorce or legal separation of the covered employee (qualifying event date) ______/______/______

c Entitlement to Medicare benefits by covered employee (qualifying event date) ______/______/______

Covered employee name ___________________________________________________ Blue Shield of California ID/SSN ________________

c Disqualification of dependent child under the plan (qualifying event date) ______/______/______

c Termination or reduction of hours due to disability (last day worked) ______/______/______

c Death of covered employee (qualifying event date) ______/______/______

c Termination of domestic partnership (qualifying event date) ______/______/______

Qualifying elector information

Last name

First name

Blue Shield ID/SSN

Address

Phone number

(street, city, state, ZIP)

(

)

Date of birth

Gender

Married?

Domestic partnership?

(month, day, year)

c Male c Female

c Yes

c No

c Yes

c No

Does qualifying elector have other health coverage?

Does qualifying elector have Medicare?

Does qualifying elector have Medicare due to disability?

c Yes

c No

c Yes

c No

c Yes

c No

If HMO, please indicate your

Phone number

Personal Physician’s name

(

)

Signature of elector

X ______________________________________________________________________________________ Date __________________

Please print signature name

X ____________________________________________________________________________________________________________

(see reverse)

Cal-Cobra Election Form - Blue Shield Of California

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